Primary Care Networks: A General Practice Odyssey
It’s 8:30am on Friday 12th Feb 2022. Fridays are our second busiest day of the week and I have just arrived at Concord Medical Centre in the Stokes Neighbourhood. I say hello to our reception team and head to our consulting suite. I am the first GP to arrive but our Clinical Pharmacist and our Physician Associate have beaten me to it. Our CP is on the phone consulting as I sit down beside them. Our PA says ‘Hi’ and lets me know it is a red day across the Neighbourhood with two GPs calling in sick so we will all need to do two consultations each, extra, to pick up the load. He has started early to make sure his 28+2 consultations are completed so he can be away for 4:30. I agree it should not be a problem. Nor should it be difficult for me to complete my 30 consultations and get away for 6:00pm.
Managing the demand and the money
This is an enormous change from just 3 years ago. The 2019 GP Contract was a practice saver but it has been working as a Primary Care Network that has had the most positive impact. The much-needed injection of cash was important, yet it is the growth in clinical workforce, which has invigorated General Practice. We now have 20 extra staff across our network of 60,000 patients, equivalent to 5 new staff for each of our 4 member practices. The clinical pharmacists now do most complex medication management but also generate extra income, from evidence based de-prescribing, via the Shared Savings Scheme. The Physician Associates are a real boon seeing undifferentiated presentations much like a GP. Our first contact physios, who should be in shortly, manage around 10% of our contacts and our community paramedics do 75% of our home visiting as well as seeing minor injuries. This reduces A&E attendance, which in return brings us income, also under the Shared Savings Scheme. Sharing these experts across practices mean that we have at least two of each, and as there is no single point of failure, resilience is increased.
At first we were worried about accommodating this expanded team but we have embraced new technology to decrease demand and increase efficiency. Digital-first has been a real success: my practice manager calls it BDR, Babylon Done Right. It is a technology tool to support patients, improve continuity and enhance the GP consultation. 40% of contacts in our PCN are now digital making the frustration for patients of morning phone congestion a thing of the past. Digital-first supports self-care and signposts to out of practice resources reducing demand. It manages a lot of our internal signposting too and takes a potted history that enables the correct in-practice disposition and identifies the patients concerns and expectations before the consultation even starts.
Getting patient records digitised, through the new contract, has freed up around 17sqm of space in each of our practices. Most practices in our PCN have created a consulting suite for up to 6 clinicians sitting together, consulting simultaneously, by phone, digitally or by video. Low bandwidth and unreliable signal for patients means that video consulting has not taken off but over 50% of patients are pleased to consult digitally or on the phone. After initial hesitancy use of the consulting suites became really popular with the ability to share knowledge across the team the instant you need to. New staff and those shared between practices love it, as it helps them feel safe and included when consulting. It is a real help in developing a more consistent approach between clinicians and practices too.
Using the consulting suite, reducing demand, spreading work over six days (no one works more than 9 clinical sessions) and sharing consulting rooms for face-to-face, has created the space in all of our surgeries to allow us to accommodate the five clinicians in our practices without needing to extend our buildings.
One practice with less pressure on space created a large meeting room. This has been essential in facilitating working across the neighbourhood. It is heavily used. This morning I see it is booked out to our PCN research group: catalyzed by central funding the PCN now employs two research nurses and we see the benefits in quality and professional improvement but the research also generates income for the PCN.
Building the team
All the GPs meet for coffee at 11:00 then we see patients face to face and do admin until 1 o’clock. Today I will pop over for the regular Friday Free lunch funded by our PCN, in the large meeting room. Everyone in our PCN, employed or attached, is welcome. This encourages the informal personal relationships that help drive collaborative working. Today I want to catch up with our community pharmacist about a patient with asthma whose peak flow has not come up, in spite of the latest inhaler. Community pharmacy are included in, and an integral part of, every clinical pathway: utilising their skills, improving patient care and reducing demand in the practice.
Later this afternoon the large meeting room will be used for our Education Hub, which brings together the training of GPs, nurses and our new AHP team members. Our education ethos is strong and valuing our medical students, GP specialty trainees and Fellowship Scheme GPs and nurses is now central to our culture. The loyalty and familiarity this brings helps massively with workforce and recruitment. This year we will employ three people who have been trained in our PCN.
Our attached team has made a real difference to the way we work. I am on first name terms with the community nurses, IAPT workers and community mental health nurses who are attached to our PCN Neighbourhood. They often pop in to discuss patients, as well as pitching up for a Friday Free lunch whenever they can. They use the EMIS Web primary care record for their consultations too. This lets us have a comprehensive overview of our patients care, to provide proper integrated care. I particularly like that our IAPT colleagues, based in practice, supported by GPs in the consulting suite, working to a Patient Group Direction, can now institute and follow up the prescription of an antidepressant (SSRI). This reduces demand on GPs and is much more convenient for patients. Benefits abound. There are wins too for our external stakeholders notably in improved staff job satisfaction, which has enormous benefits for them in staff retention.
After lunch following a bit more admin I will be back in our consulting suite again where I will be doing a joint, virtual, clinic for an hour with a local cardiologist, discussing complex patients. At times we bring patients into a three-way phone consultation. Scheduled, joint, virtual clinics with consultants and GPSIs are increasingly becoming ad hoc, enabled by cross-organizational cloud comms, voice and video, via our Bistech system. Based on the Super Six model, ready access to consultant advice and with out-patients clinics using the EMIS web record I get support when I need it for complex patients. Rather than taking more time this saves time as I am equipped to readily manage the patient in front of me and any similar patient I see in the future. With this support it feels so much less risky than before.
Specialists now manage their own results and prescriptions via Electronic Prescription System (EPS), for patients in the community using EMIS Web, rather than asking me to do it. This has removed considerable frustration from my working day and created real respect and recognition for what we do as GPs from our secondary care colleagues. It also brings us us extra income through the Shared Savings Scheme. Their use of Emis Web and EPS in outpatients has helped them meet the reduction in face-to-face outpatient appointments and use of the EPS, required of them by the Long Term Plan, without work landing on us in General Practice.
Remote consulting by specialists is soon to bring an unexpected bonus as a model with them seeing a few patients face-to-face in a practice and topping up with a virtual clinic from a practice location that allows us to meet and develop relationships with our specialist colleagues, is to start next week.
A good afternoon
In the last part of the day I will do six face-to-face consultations at an average 15 minutes per consultation but I often flex times up and down to meet the needs of my patients. Unless I am duty doctor I usually get away at six and in the summer, without winter pressures, it can be much earlier but I always check in that duty doctor is on top of things, as she always does for me when I am duty, then I head home.
So that was my day. Thanks for reading about it.